Level: Advanced
Difficulty: Hard
Subtopic: Crisis intervention
NCLEX: A 16-year-old adolescent on an adolescent psychiatric unit is being evaluated for acute emotional crisis. Assessm…
Psychiatric / mental health nursing Psychosocial Integrity
Case Study
A 16-year-old adolescent on an adolescent psychiatric unit is being evaluated for acute emotional crisis. Assessment data include the client states, "I don't want to live anymore" and has a plan with access to means. Which communication to the oncoming nurse or provider is most appropriate?
Question
A. "The client is doing fine; no issues to report."
B. Vague statements without measurable assessment data.
C. Blaming the client for nonadherence instead of stating facts.
D. SBAR format with specific objective findings, current status, and a clear recommendation.
B. Vague statements without measurable assessment data.
C. Blaming the client for nonadherence instead of stating facts.
D. SBAR format with specific objective findings, current status, and a clear recommendation.
Rationale
Correct answer: D. SBAR format with specific objective findings, current status, and a clear recommendation.
Rationale: Handoff and escalation require concise, objective communication such as SBAR with current assessment data.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Handoff and escalation require concise, objective communication such as SBAR with current assessment data.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.